Fatal error: patient dies in hospital after confusing medication

Confused infusion: patient dies in intensive care unit
A patient died in an Austrian clinic because he was given a calcium chloride magnesium chloride infusion instead of a “special” potassium / magnesium infusion. In Germany, too, deaths have already occurred in hospitals due to confusion.

More and more treatment errors
Treatment errors in medical practices or hospitals are unfortunately not uncommon. According to an older message from the Medical Service of the National Association of Statutory Health Insurance Funds (MDS), more and more patients are affected. A particularly dramatic case was reported last year from Duderstadt in Lower Saxony. A patient had died there because of false blood. In Austria, too, there was now a deadly mix-up.

Confused infusion
In the state hospital in Kirchdorf an der Krems (Upper Austria), an unfortunate death occurred due to a medication mix-up.

As the Oberösterreichische Gesundheits- und Spitals-AG spaghetti, to which the LKH Kirchdorf belongs, writes in a press release that the deceased patient received a calcium / magnesium / magnesium chloride infusion instead of a potassium / magnesium "special" infusion.

The 61-year-old patient died in a Viennese clinic due to the consequential damage caused by the wrong medication.

An allergic reaction was initially suspected
According to the information, the patient was admitted to LKH Kirchdorf on September 30 for atrial fibrillation and then transferred to the intensive care unit. Among other things, the laboratory findings showed a potassium deficiency.

Thereupon the medical prescription of potassium / magnesium “special” took place along with other medications for atrial fibrillation.

After the start of the infusion by a nursing staff member, the patient complained of a burning sensation in the mouth, face and in both hands and had an increased heart rate.

At this point, an allergic reaction was suspected, which is why a certain drug was discontinued. However, the potassium / magnesium infusion was continued and administered in full.

A little later, the patient was found to have elevated calcium levels and counter therapy was initiated.

The general condition of the Upper Austrian improved at first, but in the following night an acute kidney failure that started was noted. Because of an acute respiratory distress syndrome, the 61-year-old was intubated and artificially ventilated.

The patient was finally transferred by helicopter to a special department in Vienna, where he died on October 3, 2017.

Other patients affected by medication confusion
According to the spag, it was discovered during research in the clinic that there was obviously a medication mix-up.

In addition, internal research does not rule out that two other patients are also affected by the same medication mix, but have not suffered any consequential health problems.

Another seriously ill patient who was also treated with the medication cannot be ruled out that she died of it.

The responsible public prosecutor's office has been informed of the respective facts and will initiate an investigation.

people make mistakes
“Unfortunately, mistakes can happen where people work, including in a hospital. Unfortunately, we cannot exclude them 100%, ”said the two Gepag board members Dr. Harald Geck and Mag. Karl Lehner.

"It is crucial, however, that errors of this type do not happen again," says Dr. Harald Geck.

According to the company, it has initiated the first immediate measures to improve the distinguishability of the medication, as well as "instructing all employees to be sensitized again, to intensively examine each medication before administration," said Dr. Harald Geck.

"It is important for us to state at this point that we have complete trust in our employees. All of them work with great commitment for the patients every day, but they work in a high-risk environment, where mistakes can unfortunately have fatal consequences, ”emphasized Mag. Karl Lehner. (ad)

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